News

Implementing the Medical Examiner System

5 October 2018

AAPT member Rachel Carline reports from the Implementing the ME system meeting late September

After some morning refreshments and a warm welcome from Dr Suzy Lishman of the RCPath. Medical Examiners Committee we were guided straight into a strategic overview by Jeremy Mean, Deputy Director of Health Ethics (DHSC) and Programme Director for the Introduction of Medical Examiners.

The event was 25% over-prescribed and it was advised there will be another one day event held later in the year and again in April 2019 ahead of the proposed rollout.

It was confirmed that there was a new vision, the Medical Examiner will be a salaried NHS role as apposed to local authority as had been originally intended (2016). Government has committed £1million funding to support the implementation of the system (Primarily towards a digital communications solution).

The roll out is expected to take place in two phases:

1) Phase one is due to commence April 2019 and is the implementation of a non-statutory Medical Examiner service within participating NHS trusts for deaths in secondary care.

Current statutory medical forms 4 & 5 will still be completed with the Qualified Attending Practitioner completing the Medical Certificate Cremation 4. The Medical Examiner will now complete the Confirmatory Medical Certificate Cremation 5. Deaths occurring within the community (primary care) will see no change during phase one.

2) Phase two aims to deliver a full suite of reform with the goal of full statutory implementation. There is a degree of clarity still required in the interim, largely dependant on parliamentary outcomes.

It is suggested that the primary care rollout will begin in urban areas first followed by rural adoption.

The Medical Examiner service is to add a layer of scrutiny, ensuring accurate cause of death on the MCCD ensuring a smoother registration of death process (within a five day time-frame), accurate and timely referrals to HMC and early detection of any clinical governance concerns.

Coronial and Medical Examiner services are independent and are the only two routes for providing scrutiny.

Pilot schemes to date have notable degrees of ‘practice variation’ between participating trusts.

The non-statutory nature of pilot schemes and the planned phase 1 rollout will continue to allow trusts to create and manage the ME system as they see fit as long as the system fulfils the 3 key outcomes:

1. >accuracy and recording of cause of death

2. Better explanation and understanding of cause of death (for the benefit of bereaved)

3. >scrutiny and effective referral to HMC as and when necessary

The system is designed to ‘help’ the bereaved, keep them as informed as possible, be time efficient and also facilitate the development of junior (and some senior) doctors with regard to accurate death certification.

Dr Aidan Fowler (National Director of Patient Safety, NHS Improvement) reiterated that the Medical Examiner will be employed in trust but made it clear that reporting will be independent.

A regional feedback structure focused on insight, infrastructure and intervention/interaction is proposed and the ME system will be overseen/led by a National Medical Examiner.

There will be a number of possible roles within trust, here listed in order of banding:

The roles will be salaried positions within the NHS under phase 1 and will be a mix of full-time/part-time posts. The roles will ensure pension provision to increase desirability.

Each trust will assign posts (positions and numbers) as they deem appropriate. These will be largely dependant on expected mortality rates.

These roles (if not already filled by those in pilot schemes) will be open for application in October 2018 and the aim is to have the successful applicants in post by December 2018.

Dr Alan Fletcher (Lead Medical Examiner for Sheffield and Chair of RCPath Medical Examiners Committee) further explained the role of the Medical Examiner.

Dr Fletcher (who has been in role of Medical Examiner since 2008) began by reiterating that the Medical Examiner service would ensure accurate MCCD, timely/accurate referral to the coroner and early detection and notification of clinical governance concerns. He then went on to explain the steps in which this is achieved.

Within 24 hours of the death being notified the Medical Examiner (or MEO) will receive patient medical records to review; scrutinising the reason for the final admission, any blood test results, notes etc.

The ME will then interact with the QAP to discuss patient treatment, conditions and the cause of death (they will not tell the QAP what to write on the MCCD but may aid in formulating acceptable wording).

The ME will then interact with the bereaved. Once this layer of scrutiny has been completed they can confirm by mutual agreement what has been recording on the MCCD.

It was made clear that there is no change to cases that require HMC referral nor does it change the verification of death or registration process.

It was reiterated that during phase one that the completion of the current statutory medical forms 4 & 5 will be unchanged, with the QAP completing the Medical Certificate Cremation 4 and a slight variation in the ME completing the Confirmatory Medical Certificate Cremation 5. The process of body examination will remain the same. The Medical Examiner service will not replace the National Mortality Case Record Review Programme or Learning from Deaths NHS. It will provide an initial filter to ensure cases are correctly signposted which will aid to avoid embarrassment, enable smooth transitions and ensure the bereaved are engaged early whilst remaining independent and transparent in practice.

There is currently a list of acceptable causes of death (unchanged from early 1900’s) used by registrars which is currently under review and due to be updated.

An e-learning programme exists through the RCPath website for effective preparation for potential Medical Examiners.

The first panel discussion of the day was focussed on the role of the Medical Examiner.

The discussion started with Daisy and Kathy explaining that it would be hospital wards, bereavement offices and mortuary logs which would provide the MEO with initial notification of a patient’s death.

It was explained that the MEO does not replace bereavement officers but instead assists with scrutiny.

There are potential for different types of MEO, they can be administrative (data entry focused), IBMS registered with clinical understanding (eligible to undertake additional tasks) or a combined role.

It was reported that the bereaved of Sheffield have given positive feedback on the system, they have appreciated the involvement and have felt ‘listened to’ especially when they have had concerns regarding the care of their loved one.

Daisy went on to explain how the MEO supports the ME by:

ensuring the correct medical records are received, liaising with the bereaved and with data entry and facilitating reviews. It was mentioned at this point that if the MEO has specific training that they could pass urgent referrals on to the coroner before the ME however it must be noted that this was then invalidated by Dr Fletcher in the Working with Key Stakeholders panel discussion.

A question was put forward asking how the medical records are sent to the MEO/ME, Daisy and Kathryn work in different areas of the UK and it was explained that in some trust areas physical, handwritten notes are used whereas others utilise entirely digital records. Local solutions will by implemented initially depending on how the trust currently works with a view to a government invested common digital solution.

Dr Golda Shelley-Frazer spoke about the relationship between the QAP and the ME. Once the ME has received and reviewed the medical records they have a very open conversation with the QAP about the deceased patient. Initially checking and confirming the identity before speaking about the final admission of the deceased, any test results, medication, and finally to ask if the QAP has any concerns or if they feel it requires referral to HMC. When asked about what happens if the QAP and ME disagree Dr Shelley-Frazer explained that, in her experience, this is a very rare occurence and can usually be resolved through conversation. Any disagreement is likely to occur over terminology used for the MCCD.

If disagreements cannot be resolved, the situation would be escalated to senior team members eg. the lead consultant.

Dr Alan Fletcher explained that in Sheffield the initial concerns dissipated quickly once it was understood that the ME role is a supportive role and intended to work alongside the doctors as a professional development aid.

The Medical Examiner service is a 24 hour, flexible service.

Routine office hours are Monday-Friday 8.00am-5.00pm however there will be an out of hours service to facilitate urgent cases such as paediatric, organ donation or religious preferences. It was noted that in Sheffield deaths are usually prioritised using the date of death unless there is a reason to fast track. It was also noted that in some ‘anticipatory’ instances it would be possible to issue a pre-prepared MCCD prior to death!?!

When discussing the time-frame for the Medical Examiner completing their duties a guide was used:

The ME is notified within 24 hours of the death taking place, they aim to complete duties within two working days of receiving the patient notes and then details are passed on to the registrar.

The only time-frame mentioned of concern was the five days from death to registration and that the ‘extra’ couple of days would ‘make no difference’. Bereaved are advised to not make funeral arrangements until the MCCD is available and to appoint a funeral director once the appointment to register is secured in a bid to manage expectations.

Coming from a funeral background myself, I do feel that the bereaved should be advised they may appoint the funeral director immediately should they wish as the funeral director can liaise and assist in the management of expectations whilst preventing any disappointment that may arise should there be a delay.

When asked how the role of the ME can be classed as independent when it is a NHS salaried position, it was explained that the ME is independent of the cases they are prescribed and that there is a minimal acceptable distance applied. To ensure independent review is respected, aside from own professional accountability applied, there are peer reviewed samples carried out as well as independent reviews by HMC and a National Medical Examiner.

The registration process remains unchanged and issues with MCCD will be directed, as appropriate, to HMC.

The role of the crematorium medical referee will also continue unchanged.

After a break for lunch the second panel discussion of the day was Working with Key Stakeholders, this was chaired by Professor Jo Martin and consisted of Kathryn Griffin, Dr Alan Fletcher, Alan Wilson – Senior Coroner, Blackpool and Professor Peter Furness – Medical Examiner, Leicester.

Alan Wilson began by explaining the guidance on when a case is referred to HMC and explained how there are variations between jurisdictions.

It was however noted that consistency is improving since the introduction of the Chief Coroner under the 2009 Coroner’s Reform Act and that it is a work in progress. Prof Furness explained that the ME is not there to ‘tell the coroner what to do’ and when training junior doctors in certification has been clear that in other areas the HMC may be looking for, or expecting something slightly different. In Leicester the ME has reduced the number of cases which require HMC referral.

An example of this given: when a patient has died after an operation; if the death would have occurred sooner without the operation it no longer needs to be referred to HMC and the scrutiny provided by the ME is sufficient.

Kathryn confirmed that in Gloucester they have experienced the same and reported that their coroner is very engaged with the system and they have also reported a reduction in post mortem examinations.

Dr Fletcher explained that in Sheffield the ME/coroner relationship is strong and they have also seen a reduction in cases referred to the coroner, he also explained that sections of the e-learning programme for the ME were made by a coroner.

The ME enables an extra layer of scrutiny which would not usually be in place if the case were not referred to HMC.

In referred cases it is paramount that there are good channels of communication between the ME and HMC.

If a case does not warrant referral as per the guidelines, the ME will discuss this sensitively with the bereaved. However, if the bereaved are unhappy with this the case can and will be referred to HMC for a definitive decision.

The impact on the Registrar was discussed next. It was reported that the pilot sites have reported mixed results.

Where engagement with the Medical Examiner system was high the results were positive. During implementation, collaboration with Registrars is required throughout. It was reiterated that the accepted cause of death list is under review to be updated and that during phase one all changes are non-statutory and so the registration process does not change.

How Will This Work in Practice - the final panel discussion of the day was chaired by Dr. Mark Howard – Former Medical Examiner and consisted of Daisy Shale, Dr Diane Monkhouse – Medical Examiner, South Tees, Julia Phillips – Nurse Lead Mortality Review, Buckinghamshire Healthcare NHS Trust and Dr Jason Shannon – National Clinical Lead for Mortality Review, Senior Responsible Officer for Medical Examiner Implementation, Wales.

Dr Shannon began by explaining in Wales they have a Mortality Review System in place and not the Learning from Death initiative. He explained how they have a screening process as opposed to a sampling process.

The ME is critical and takes the lead using personal judgement. The idea behind implementing the ME service into our trusts is to utilise the current hospital set up using local solutions and as Daisy said “not to re-invent the bereavement wheel”.

As the discussion moved on to funding and how it will be implemented for primary care it is safe to say there are still a number of grey areas.

Hospital trusts cannot use mortality rates alone to forecast finances generated because burials and children under the age of 18 years do not contribute, as it is only the fee from the completion of the statutory medical form 5 which forms the funding.

The figure for how much each trust will require also depends on the number of ME/MEOs required depending on the anticipated mortality rate.

Government supplement funding was touched on briefly (projected at £100 per expected burial/<18) as was how the charge is passed on to the bereaved.

Currently the fees for the completion of the statutory medical forms 4 & 5 are paid for by the funeral director who then charges the bereaved as a disbursement cost.

I must note, at this point it was said that funeral directors do not break down their fees and that insinuates that bereaved would not know if a QAP or ME has been paid. However, again coming from a funeral background with a corporate company, I can safely say that as per the National Association of Funeral Director Guidelines we are fully transparent in our disbursements and who has been paid on the clients behalf.

With regards to phase two and how the system will be implemented in primary care it is not yet known how it will work practically.

It is yet to be determined if it will be general practitioners or in hospitals where duties will be carried out. Will GPs become trust MEs? Gloucester and Sheffield are currently piloting how it will work for primary care, currently sampling 30-40 cases per month. This is currently being done by medical records being scanned and emailed or faxed from the GP to the ME.

A great deal of information was shared at the event, answering a vast number of questions but also creating many new ones. The follow up event which will take place in due course will make for an interesting day.